Rozell, Alan rl-O%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �l Ron T �. � Case #
Date of Cremation
Time Cremation Started (�
Time Cremation Completed D 0
Type of Container GIA w Mom-;-\ 6g-
Remarks :
� �57�i �
a v -�
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i
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows:
Mail to
�_
Other arrangements please specify ni v� + -�-e _
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week 7:00
A.M. - 3:30 P.M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Pre-arrangements by
telephone for acceptance of remains is necessary.*
2. Pine View Crematorium s located on
Queensthe grounds of the Pine
View Cemetery, Quaker Road,
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the power and authority to arrange for the cremation of the
remains and to direct the disposition of the cremated remains,
that any personal possessions have either been removed or may be
destroyed and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of said
directed, whether such claims or demands are, or are
remains as
not wholly groundless, falsburial oermit mustnaccompanyatheoremains. in
addition to a regular t
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible
material. No Styrofoam or plastic containers will be accepted.
5. The question relato cremate to diac pacemers form before the must
rema ins will rbe
ed
on the authorization t
accepted.
6. Unless other arrangemen
ts are made the cremated remains will
be mailed via Registered
S• Mail
servicen three
Theredays
willobecae$25100
to the funeral home handling the
charge for this service.
Cremation, -00
Administration Costs year s)e $1501 00 cording Fe Infants t (sti�lborn
Children (age 13 months to 12 y
months)to 12 mo ) $100.00 �
* Additional $100.00 charge for cremations done after 3:00 P.M.
Friday. Cremations done on Saturdays will 3e
Monday throughy remains received after 3..
charged the additional $100. 00 Any
P.M. Mon-Fri or Saturday will be charged an additional $100.00.
I
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
Yyi �U-z
(NAME) i t (SEX)
So [&-Z F z L w '1 y GJ, ,,7A-A A 7
(STREET) (CITY) (STATE) (ZIP CODE)
who died on c day of f 20,
at S ��}LL.S %�oSA� 1�- Z. �g �� �_ �1�}LL1 ) ZF a/
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased 4121 �h
Name of Funeral Home 1::'
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains,that any personal possessions have either been
removed or may be destroyed,and agree to protect, defend and save harmless Pine View
matorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed,whether
such claims or de nds are or are not wholly groundless, false or fraudulent
(WITNESS) ADDRESS)
GNATURE OF RELATIVE OR GAL REP.AND ADDRESS)
Signed on this date: 7 / D .